Avoiding Early Cancer Claims Presentation # 3 Hank George, FALU
LABORATORY TEST RED FLAGS
Low Cholesterol
Low even more so, progressively falling serum TC is a marker for preclinical cancer that is most likely to be apparent in 2 years Does not apply to cases on hypolipidemic Rx Strongest correlation when also low serum albumin and/or parallel decreases in HDL-C and triglycerides Also correlates with longtime heavy smoking, unexplained weight loss
PSA High grade (Gleason 8-10 adenocarcinoma, small cell carcinoma) cancersa often have low PSA levels because anaplastic cells do not manufacture PSA efficiently RED FLAG: PSA < 2.5 (and no matter how low) that increases at 1 ng per year Often ignored in primary care because it is within normal range Undetectable PSA = undisclosed radical prostatectomy or poor-prognosis neuroendocrine carcinoma of prostate
Simultaneous elevations of both GGT and alkaline phosphatase (AP) suggest intra- and extrahepatic bile duct lesion. Must be further evaluated clinically to rule out cholangiocarcinoma, etc.
Pancreatic Carcinoma is one of the main malignant neoplasms accounting for death claims within 2 years. This is readily explained by 3 factors: Rising incidence, now #4 Nonspecific symptoms High mortality rate due to late detection
RED FLAGS in Pancreatic Carcinoma Elevated GGT and AP Dull epigastric pain, often accompanied by back pain, made worse in supine position and relieved by sitting forward Excessive bloating/belching Clay-colored (acholic) stool, dark urine Generalized pruritus Persistent anorexia
Worsening fatigue Cholecystitis diagnosis within 6 months Chronic pancreatitis at any time Family history pancreas carcinoma in a 40 pack-year smoker; doubly so if obese Family history of BRCA-1, BRCA-2 carriers Type T3c diabetes
Bottom Line: Our best chance of avoiding pancreatic cancer death claims is to identify recently-diagnosed type 2 diabetics at high risk for actually being type 3c diabetics
Type 3c Diabetes At least 5% of new onset DM 50 = T3cDM 80% of these initially misdiagnosed as Type 2 8-10% already have or will develop pancreatic cancer, usually within 1 year Over 50% also have chronic pancreatitis, that may be subclinical and undiagnosed Type T3c can be easily diagnosed by a meal test that is seldom done in primary care
RED FLAGS for T3c Diabetes Sudden and often symptomatic onset Underweight/low normal weight, recent weight loss No diabetic family history; pancreatic cancer family history Low insulin and glucagon levels
Episodes of post-diagnosis hypoglycemia Comorbid hepatitis C Hypoglycemic Rx resistant, requiring insulin early on Prior history of acute pancreatitis Pancreatic enzyme replacement at any time
In a recent obituary in the British Medical Journal Female physician diagnosed with curable breast cancer at age 31 Had a recurrence 19 years later Died in < 12 months despite treatment
Prior History of Cancer? Pay attention to every RED FLAG for potential recurrence/second tumor no matter how long ago the original malignancy was diagnosed
RED FLAGS (unless adequately investigated to r/o cancer recurrence) New onset atypical headaches New onset localized neurological deficits New onset highly localized and otherwise unexplained pain Newly-discovered elevations of liver-related tests if with no apparent explanation or prior history of elevated LFTs Recent seizure or suspected syncope episode Newly discovered lymphadenopathy Childhood/adolescence cancer treated with radiation and/or cancercausing chemotherapy (alkylating agents, etc)
Recommended FREE model drilldown questionnaire for applicants with a history of childhood/adolescent cancer: Insureintell.com/content/teleinterview-drilldown-questionnairechildhood-cancer-survivors#attachments
Ductal carcinoma in situ (DCIS) of the breast is a standard risk. No reason to be concerned about new application 5 years later, right? Wrong!
University of Toronto oncologists looked at 108,196 carefully selected patients with DCIS from 18 database registry studies
Standardized mortality ratio when diagnosed at age 30-34 was 17.0 and at age 35-39 it was 7.3 versus far lower thereafter 54% who died did not experience an invasive in-breast recurrence (ipsilateral or contralateral) prior to death, most deaths due to distant metastases No significant difference based on type of treatment (mastectomy vs. lumpectomy + radiation) Highest risk: poorly differentiated DCIS comedocarcinoma subtype, 5.0 cm at diagnosis. What s in your manual?
To make matters worse, one oncologist advocates telling DCIS patients they were treated for an indolent lesion of epithelial origin pretty well assuring it won t be mentioned in some cases we see!
In their frenetic obsession with speeding up underwriting, (often without regard to consequences) some companies now lump together nonmelanoma skin cancer and papillary thyroid carcinoma as 2 cancers that do not have to even be acknowledged on the Part 2. Is this wise if you want to avoid early death claims? NO!
There is a huge difference between papillary microcarcinoma, which almost always has an excellent prognosis and micropapillary carcinoma, an aggressive neoplasm with a poor prognosis
Why do you want a path report on all papillary carcinomas diagnosed within 2 years? Because you don t want to see any of these RED FLAG pathology report findings Tall cell Columnar Insular Hobnail (same as micropapillary) Poorly-differentiated Solid foci/areas
HIGH RISK in Thin Melanoma Level III/IV (vertical growth phase) tumor with marked, severe or total regression Average duration of flat extra: 1-3 years since diagnosis Average duration from diagnosis to death in high risk thin melanoma: 5-7 years What s in your manual?
If the applicant says he had a nonmelanoma skin cancer, there is no reason to get more information, right? Wrong! Merkel cell carcinoma is a highly malignant nonmelanoma skin cancer
Painless round and solitary pink/purple to red/brown, dome shaped papule or plaque Neither pruritic nor tender Often mistaken for BCC, SCC, cyst, pyogenic granuloma, even phlebitis = delayed diagnosis means high % with regional/distant metastases Incidence has tripled in last 20 years Median age 70 34% have with coexisting/later hematological cancer
RED FLAG Cancer Presenting in Emergency Room 23% of all UK cases; mainly < age 24 or age 70 1 year relative survival: all diagnosis vs. ER diagnosis only: Melanoma: 97% vs. 61% Non-Hodgkin Lymphoma: 74% vs. 46% Oral Cavity: 82% vs. 56% Bladder 72% vs. 35% Prostate 95% vs. 54%